Laserfiche WebLink
Submit to noir-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin <br /> municipalities for new 1- PERMIT APPLICATION Safety and Buildings Division <br /> and 2- family dwellings (Wis. Stats. 101.63 (7) & 101.65 (3)) <br /> SEE INSTRUCTIONS ON BACK OF SECOND FLY <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> r.. x :, tt,. , • :F.,r,,. r p' .,y .i:" ry ..: r.xr.. ,g5 W' C l`("`i�3V <br /> Inh it/Al 5 <br /> Last Name First Name Middle Initial <br /> Street Address <br /> City State Zip Code Telephone No. (Include area code) <br /> S` '0U d <br /> 7Bdin7AddreSubdivision Name Lot# Block# <br /> 3 <br /> IVLegal DeParcel No. <br /> 5141 1/4, bjj4j 1/4, Section T N, R�� or W p <br /> • \� .' q tt ate+ �/y1 � ': �'�\\� !, <br /> q \ <br /> 1 Family ❑ Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Family ❑ Boiler ❑ Central AC Other: <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ ❑ P ❑ <br /> Water Heating ❑ ❑ L;x ❑ ❑ ❑ <br /> 'h ES <br /> j \.v y \ '' <br /> fiiL Site Constructed Concrete ❑ Masonry ❑ Treated Wood <br /> ❑ Manufactured(to the WI UDC; not U.S. HUD code) ❑ Other(s ecif ): <br /> y <br /> I3V LDI1� <br /> Living area= Square Feet $ <br /> I vouch that all the above information is correct,and understand that the issuance of this permit is for administrative purposes only. I <br /> understand that onsite construction inspections will not be performed by the municipality,but that the Uniform Dwelling Code, <br /> Chapters Comm 20-25,still applies to all new I-and 2-family dwellings and must be complied with. I understand that the issuance of <br /> this permit does not relieve me of compliance with other applicable codes and ordinances. <br /> A lic ignature Date Si ed <br /> MUST BE COMPLETED BY THE MUNICIPALITY BEFORE FORWARDING PLY 2 TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> Town ❑ Village ❑ City ❑ County of: i` <br /> liZ<? i <br /> Nov" �--11 1, <br /> � v <br /> � l <br /> SBD-8254 (R.2/00) Distribution: ❑Ply 1-Issuing Jurisdiction ❑Ply 2-Municipality Forwards to State If New Dwelling ❑Ply 3-Applicant <br /> MUNICIPALITY FORWARDS TO STATE WITHIN 30 DAYS IF NEW DWELLING <br />